Sesamoidectomy is the surgical procedure used in particularly serious injuries to one or both of the sesamoids, the small bones located beneath the main joint of the big toe. Typically, more conservative treatments, such as taping, bracing, a cast, or special shoe are recommended to allow the injury to heal and sesamoidectomy is required only with chronic pain that has not responded to treatment.
What Are Sesamoids and a Sesamoidectomy?
Sesamoid comes from the Greek sēsamoeidēs, which means “resembling a sesame seed” and is meant to describe its small size, although it is really more the size of a corn kernel. What actually defines a sesamoid bone, though, is not its size but that it is not connected to another bone at a joint, like most of the other bones in the human body, but, instead, it is embedded in tendon or muscle.
Most people have two sesamoid bones below the big toe. One of these is located on the medial side of the first metatarsal, meaning away from the midline of the body, and the second one is on the lateral side, which is away from the middle.
A more well-known sesamoid bone is the patella (kneecap), which is also the largest. Like the patella, the sesamoids embedded in the tendon beneath the forefoot at the big toe act like pulleys and facilitate movement by providing a smooth surface for the tendons to glide across. This not only increases the leverage of these tendons, it also allows them to sustain the considerable force and pressure that is exerted each time the big toe is called upon for forward movement.
Types of Sesamoid Injuries in the Forefoot
There are different types of injuries that can affect the sesamoid bones beneath the big toe. These include:
- Sesamoiditis – this is a form of tendinitis resulting from overuse that causes chronic inflammation in and around the sesamoid bones and associated tendons. Other symptoms are swelling, bruising and pain in the ball of the foot near the big toe, especially when bending or straightening the toe. Sesamoiditis is often found in those whose activities include the types of repetitive movements required by runners, ballet dancers, golfers, tennis players, and baseball catchers.
- Turf toe – this is the term commonly used when a sprain results from overextension of the ligaments surrounding the big toe joint. Symptoms of turf toe typically include swelling, pain and decreased mobility.
- Fracture – even small bones encased in soft tissue are susceptible to fracture and the sesamoids at the base of the big toe are no exception. These fractures may be acute, meaning that they are the result of some sort of impact to the bone, or they may develop over time from repetitive stress or overuse. The latter is a chronic fracture, also referred to as a stress fracture. Both types of fracture produce pain and swelling, although the symptoms associated with a chronic fracture tend to come and go.
Diagnosing Sesamoid Injuries
During the initial examination, the orthopedic surgeon will look for tenderness in response to pressure on the area beneath the big toe. Pain, stiffness and the presence of a grinding sensation during movement of the toe are indicators of a sesamoid injury.
X-rays will be taken of the area to rule out other possible causes of the symptoms, including the presence of arthritis, and to ensure a correct diagnosis. These may be followed with an MRI or CT scan to check for fractures, fragmenting of the bone or bone bruising.
Sesamoid Injury Treatment Without a Sesamoidectomy
Treatment of a sesamoid injury, which is typically conservative and non-surgical, will depend on the type and extent of the damage. In the case of sesamoiditis, treatment will generally consist of:
- ceasing activity causing pain
- rest, ice and aspirin or ibuprofen to reduce pain and swelling
- comfortable shoes and cushioning pad to relieve stress
- avoid placing weight on balls of the feet as much as possible
- steroid injection may be recommended
- gradual return to normal activities
For a turf toe injury, the typical recommended treatment includes:
- R.I.C.E protocol of rest, ice, compression and elevation
- over-the-counter medications for pain and inflammation
- cast boot or crutches to restrict movement and keep weight off joint
- surgery, which is rare for turf toe, would consist of repairing any soft tissue issues and restoring the MTP (metatarsophalangeal) joint motion
Sesamoidectomy is the surgical option when conservative treatment measures are not effective in relieving the pain and inflammation caused by fracture or other damage to the sesamoid bone. Performed under regional ankle anesthesia, the surgeon will make a small incision on the side or bottom of the foot, remove the affected sesamoid bone and make necessary repairs to the surrounding tendon. The incision is then closed, and the patient will go home the same day in a splint or surgical boot.
Following a sesamoidectomy, the affected foot should be elevated as much as possible for several days and movement limited. For the next couple of weeks, crutches should be used to keep weight off of that foot. Recovery and gradual return to normal activities usually takes about 3 months.